The U.S. Department of Health & Human Services’s (“HHS” or ... · 1/24/2020 · U.S....

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Office of the Director ● Humphrey Building

200 Independence Ave, S.W.● Washington, D.C. 20201

Voice: (800) 368-1019 ● TDD: (800) 537-7697

Fax: (202) 619-3818 ● www.hhs.gov/ocr

VIA CERTIFIED U.S. MAIL AND ELECTRONIC MAIL [[email protected]]

The Honorable Xavier Becerra

Attorney General

State of California

Department of Justice

1300 I Street

Sacramento, CA 95814

January 24, 2020

Notice of Violation -- OCR Transaction Numbers 17-274771 and 17-283890

Dear Governor Newsom, Attorney General Becerra, Secretary Ghaly, and Director Rouillard:

The U.S. Department of Health & Human Services’s (“HHS” or the “Department”) Office

for Civil Rights (“OCR”) has completed its investigation of the complaints filed by Missionary

Guadalupanas of the Holy Spirit, Inc. (OCR Transaction Number 17-274771)1 and Skyline

Wesleyan Church (OCR Transaction Number 17-283890)2 (collectively, the “Complainants”).

OCR finds that the State of California (“California”) has discriminated, in violation of the Weldon

Amendment,3 against health care plans and issuers4 that did, or would, limit or exclude abortion

1 Letter from REDACTED Attorney, REDACTED., to Michael Leoz, Regional Manager, Office for Civil Rights,

U.S. Dep’t of Health & Human Servs. (June. 26, 2017) (on file with HHS OCR) [hereinafter “Guadalupanas Sisters

Complaint”].

2 Letter from REDACTED, Attorney, REDACTED, to Office for Civil Rights, U.S. Dep’t of Health & Human Servs.

(Sept. 22, 2017) (on file with HHS OCR) [hereinafter “2017 Skyline Complaint”].

3 See, e.g., Consolidated Appropriations Act, 2018, Pub. L. No. 115-141, Div. H, § 507(d), 132 Stat. 348, 764 (Mar.

23, 2018) [hereinafter “2018 Weldon Amendment”]; Department of Defense and Labor, Health and Human Services,

and Education Appropriations Act, 2019 and Continuing Appropriations Act, 2019, Public Law 115–245, Div. B.,

sec. 507(d), 132 Stat. 2981, 3118 (Sept. 28, 2018), as extended by the Continuing Appropriations Act, 2020, and

Health Extenders Act of 2019, Pub. L. No. 116-59, Div. A., sec. 101(8), 133 Stat. 1093, 1094 (Sept. 27, 2019)

[hereinafter “2019 Weldon Amendment”]; Department of Defense and Labor, Health and Human Services, and

Education Appropriations Act, 2019, and Continuing Appropriations Act, 2019, Public Law 115–245, Div. B., sec.

507(d), 132 Stat. 2981, 3118 (Sept. 28, 2018), as extended by the Further Continuing Appropriations Act, 2020, and

Further Health Extenders Act of 2019, Pub. L. No. 116-69, Div. A., sec. 101(1), 133 Stat. 1134 (Nov. 21, 2019)

[hereinafter “2020 CR Weldon Amendment”]; Further Consolidated Appropriations Act, 2020, Pub. L. No. 116-94,

Div. A., § 507(d), 133 Stat. 2534, 2607 (Dec. 20, 2019) [hereinafter “2020 Weldon Amendment”].

4 Under California law, a health care service plan is “[a]ny person who undertakes to arrange for the provision of

health care services to subscribers or enrollees, or to pay for or to reimburse any part of the cost of those services, in

return for a prepaid or periodic charge paid by or on behalf of the subscribers or enrollees.” CAL. HEALTH & SAFETY

CODE § 1345(f)(1). The “plan” “refers to the entity that offers health coverage, as distinct from one of more ‘products’

covering a specific package of benefits and services that a plan may offer to purchasers.” Letter from REDACTED,

Gen. Counsel & Deputy Dir., Dep’t of Managed Health Care, Cal. Health & Human Servs. Agency, to Michael Leoz,

Regional Manager, Office for Civil Rights, U.S. Dep’t of Health & Human Servs., at 2 n.3 (Nov. 1, 2017) (on file

with HHS OCR) [hereinafter “2017 DMHC Data Response”]. For purposes of this Notice of Violation, the term

U.S. Department of Health and Human Services

Office for Civil Rights


200 Independence Ave S.W. ● Washington, D.C. 20201

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coverage, by mandating abortion coverage in plans subject to regulation by the California

Department of Managed Health Care (“DMHC”).

BACKGROUND

The Knox-Keene Health Care Service Plan Act of 1975 (“Knox-Keene Act”)5 requires

health plan issuers operating in California to provide seven categories of “basic health care

services” in their plan products. California’s DMHC licenses health plan issuers in the state6 and

has authority to determine the scope of basic health care services under the Knox-Keene Act.7 In

2013, Loyola Marymount University and Santa Clara University, two religiously affiliated

universities in California, implemented changes to their employee health care plans to no longer

provide elective abortion coverage—changes that DMHC had previously approved.8

Abortion providers and advocacy groups, including Planned Parenthood, learned of this

development and pressured DMHC to not only reverse its decision to allow the coverage changes,

but also to make elective abortion coverage mandatory for all health care plans falling under

DMHC’s jurisdiction.9

On August 22, 2014, DMHC responded to the pressure campaign by sending letters to

seven California health care service plan issuers (the “Health Plan Issuers”) mandating they cover

“issuer(s)” or “health plan issuer(s)” refers to a “health care service plan” as defined under California law, and the

terms “plan(s)”, “health plans”, “health care plans”, or “plan products” refers to the products covering a specific

package of benefits and services that an issuer may offer to purchasers.

5 CAL. HEALTH & SAFETY CODE § 1340 et seq.

6 See CAL. HEALTH & SAFETY CODE § 1349 (requiring licensure unless exempted by § 1343 of California’s Health

and Safety Code).

7 “The director shall by rule define the scope of each basic health care service that health care service plans are required

to provide as a minimum for licensure under this chapter.” Id. at §§ 1367(i), 1345(b); CAL. CODE REGS. tit. 28, §

1300.67.

8 See OCR Interview with REDACTED, Vice Pres., California Catholic Conference, et al. (March 12, 2015) (on file

with HHS OCR).

9 See E-mail from REDACTED, Managing Attorney, Nat’l Health Law Prog., (“NHLP”) to REDACTED, Dir.

DMHC (Nov. 8, 2013) (on file with HHS OCR) (requesting to arrange a meeting between DMHC, NHLP, and other

“allies” to address the “sensitive topic” of LMU’s and SCU’s decision to not cover elective abortions in their employee

health plans). From November 2013 through Spring 2014, Planned Parenthood (lead by its Chief Legal Counsel,

REDACTED) and, to a lesser extent, other advocacy groups, lobbied DMHC, CHHSA, and the California

Governor’s Office for a legislative or administrative “fix” for “the ongoing issue of DMHC approval of employee

plans that exclude abortion coverage.” E-mail from REDACTED, Legislative Advocate, Planned Parenthood, to

REDACTED, Dep. Sec., CHHSA (March 17, 2014) (CHHS000052) (on file with HHS OCR). The weight of the

details regarding the lobbying effort, including California’s requesting legal guidance from Planned Parenthood, are

found in the trial court record in Skyline Wesleyan Church v. Cal. Dep’t of Managed Health Care, No. 16-cv-0501

(S.D. Cal. 2016). See, e.g., Pl.’s Separate Statement Undisputed Material Facts Supp. Mot. Summ. J., Skyline Wesleyan

Church v. Cal. Dep’t of Managed Health Care, No. 16-cv-0501 (Dkt. # 92-5) (S.D. Cal. March 9, 2018), and the

declarations, depositions, and exhibits referenced therein. See also OCR Telephone Interview with REDACTED,

Assoc. Gen. Counsel, Blue Cross of California, dba Anthem Blue Cross (Feb. 26, 2015) (on file with HHS OCR)

[hereinafter “Anthem Blue Cross Interview”] (recounting Planned Parenthood’s advocating to DMHC that it

implement the change in policy quickly).





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abortion without exclusion or limitation in every plan product they offered (collectively, the

“Mandate Letters”). The Health Plan Issuers were:

1. Aetna Health of California, Inc. (“Aetna”);10

2. Blue Cross of California, dba Anthem Blue Cross (“Anthem Blue Cross”);11

3. California Physicians’ Service, dba Blue Shield of California (“Blue Shield”);12

4. Health Net of California, Inc. (“Health Net”);13

5. Kaiser Foundation Health Plan, Inc. dba Kaiser Foundation, Permanente Medicare Care

Program (“Kaiser”);14

6. GEMCare Health Plan, Inc., dba ERD Inc., Physicians Choice by GEMCare Health Plan

(“GEMCare”);15 and

7. UnitedHealthcare of California (“UnitedHealthcare”).16

Prior to sending the Mandate Letters, DMHC did not have any written r u l e s , policies,

or procedures related to abortion coverage for the health care plans under its jurisdiction.17 The

Mandate Letters, and the change in position they announced, were issued without prior public

notice, public comment, or hearing.18

10 See Letter from REDACTED, Dir. Cal. Dep’t of Managed Health Care, to REDACTED, Pres. Aetna, (Aug. 22,

2014), https://www.dmhc.ca.gov/Portals/0/082214letters/aetna082214.pdf [hereinafter “Aetna Letter”].

11 See Letter from REDACTED, Dir. Cal. Dep’t of Managed Health Care, to REDACTED, Cal. Pres. of Anthem

Blue Cross, (Aug. 22, 2014), https://www.dmhc.ca.gov/Portals/0/082214letters/abc082214.pdf.

12 See Letter from REDACTED, Dir. Cal. Dep’t of Managed Health Care, to REDACTED, Pres. & Chief Exec.

Officer, Blue Shield of Cal., (Aug. 22, 2014), https://www.dmhc.ca.gov/Portals/0/082214letters/bsoc082214.pdf.

13 See Letter from REDACTED, Dir. Cal. Dep’t of Managed Health Care, to REDACTED, Pres., W. Region Health

Plan & Pres., Health Net, (Aug. 22, 2014), https://www.dmhc.ca.gov/Portals/0/082214letters/hn082214.pdf.

14 See Letter from REDACTED, Dir. Cal. Dep’t of Managed Health Care, to REDACTED, Senior Vice-Pres., Cal.

Health Plan Operations, Kaiser, (Aug. 22, 2014), https://www.dmhc.ca.gov/Portals/0/082214letters/k082214.pdf.

15 See Letter from REDACTED, Dir. Cal. Dep’t of Managed Health Care, to REDACTED, Chief Exec. Officer,

GEMCare, (Aug. 22, 2014), https://www.dmhc.ca.gov/Portals/0/082214letters/gc082214.pdf.

16 See Letter from REDACTED, Dir. Cal. Dep’t of Managed Health Care to REDACTED, UnitedHealthcare, Pres.

& Chief Exec. Officer, (Aug. 22, 2014), https://www.dmhc.ca.gov/Portals/0/082214letters/uh082214.pdf.

17 Sept. 27, 2017 Deposition of REDACTED, former Dep. Dir. Office of Plan Licensing, DMHC (on file with

HHS OCR) 41:18-21; Sept. 19, 2017 Deposition REDACTED, Dep. Dir. Leg. Affairs, DMHC (on file with HHS

OCR) 15:18-16:13, 17:20–24; Sept. 20, 2017 Deposition of REDACTED former Dep. Dir. Plan & Prov. Relations,

DMHC (on file with HHS OCR) 29:13-17 (“. . . DMHC didn’t seem to have a policy on this issue and hadn’t done—

it seemed to me that they hadn’t done the—the research in regards to whether or not that—what its policy should be in

regards to those exclusions . . .”).

18 Consolidated Opening Br. Pet., Opp’n Demurrer, & Supp. Writ Mandamus & Declaratory Relief at 4, Missionary

Guadalupanas of the Holy Spirit, Inc. v. Rouillard, No. 34-2015-80002226 (Cal. Super. Ct. Aug. 12, 2016).

https://www.dmhc.ca.gov/Portals/0/082214letters/abc082214.pdf

https://www.dmhc.ca.gov/Portals/0/082214letters/bsoc082214.pdf

https://www.dmhc.ca.gov/Portals/0/082214letters/hn082214.pdf

https://www.dmhc.ca.gov/Portals/0/082214letters/k082214.pdf

https://www.dmhc.ca.gov/Portals/0/082214letters/gc082214.pdf

https://www.dmhc.ca.gov/Portals/0/082214letters/uh082214.pdf





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As a result of its edict, California forced over 28,000 people out of plans that up until that

time had chosen to not cover elective abortions.19

As described further below, OCR’s current investigation was prompted by complaints

alleging that California’s actions directly caused Complainants to lose health care plans that were

consistent with their sincere moral or religious beliefs regarding their objection to helping pay for

or facilitate elective abortion.20

BACKGROUND OF THE COMPLAINTS

1. Missionary Guadalupanas of the Holy Spirit, Inc. (“Guadalupanas Sisters”)

The Guadalupanas Sisters are a Catholic order of religious women organized as a Florida

nonprofit corporation and headquartered in Los Angeles, California.21 The Guadalupanas Sisters

“endeavor to creatively live the attitudes modeled by Our Lady of Guadalupe: presence,

accompaniment, solidarity and compassion towards the poorer people, especially the indigenous,

migrants, and the marginalized.”22 The Guadalupanas Sisters are “faithful to the moral and

theological teachings of the Roman Catholic Church” 23 and “believe that direct abortion, abortion

willed either as an end or a means, is gravely contrary to the moral law.”24 On June 26, 2017, the

Guadalupanas Sisters filed a complaint with OCR alleging that the Mandate Letters “burden[] their

conscience rights by compelling them to fund, through their premiums payments [to Kaiser], the

practice of abortion on demand for other plan participants.”25

19 Letter from REDACTED, Gen. Counsel & Deputy Dir., Dep’t of Managed Health Care, Cal. Health & Human

Servs. Agency, to Michael Leoz, Regional Manager, Office for Civil Rights, U.S. Dep’t of Health & Human Servs.,

at 5 (Jan. 20, 2015) (on file with HHS OCR) [hereinafter “2015 DMHC Data Response”].

20 Pursuant to 45 C.F.R. sections 88.1 and 88.2 (effective March 25, 2011), OCR receives and handles complaints

concerning alleged violations of the Weldon Amendment in coordination with HHS funding components as

appropriate. See also Statement of Organization, Functions, and Delegations of Authority, 83 Fed. Reg. 2,802, 2,803

(Jan. 19, 2018). This notice of violation does not rely on the final rule published on May 21, 2019, “Protecting

Statutory Conscience Rights in Health Care; Delegations of Authority,” 84 Fed. Reg. 23,170, which has been vacated

by courts in ongoing litigation. See New York v. U.S. Dep’t of Health & Human Servs., 2019 WL 5781789, at *70

n.76 (S.D.N.Y. Nov. 6, 2019) (“The 2011 Rule, which has governed HHS’s administration of the Conscience

Provisions for eight years and is unaffected by this decision, will remain in place, and continue to provide a basis for

HHS to enforce these laws, pending any future rule that HHS may promulgate.”); Id. at *72 (“The Conscience

Provisions recognize and protect undeniably important rights.”); City and County of San Francisco v. Azar, 2019 WL

6139750 (N.D. Cal. Nov. 19, 2019); State of Washington v. Azar, 2019 WL 6219541 (E.D. Wash. Nov. 21, 2019).

21 V. Pet. Writ Mandamus & Compl. Injunctive & Declaratory Relief & Attorneys’ Fees at ¶¶ 12-13, Missionary

Guadalupanas of the Holy Spirit, Inc. v. Rouillard, No. 34-2015-80002226 (Cal. Super. Ct. Oct. 26, 2015).

22 Misionares Guadalupanas del Espíritu Santo, About Us, Charism, http://mgsps.org/carisma-charism/ (last visited

Jan. 23, 2020).

23 V. Pet. at ¶ 14, MGHS v. Rouillard (2015).

24 Id. at ¶ 16.

25 Guadalupanas Sisters Compl. at 2. The Guadalupanas Sisters had previously “procured their insurance through a

federally qualified Employee Retirement Income Security Act (“ERISA”) trust available to certain, qualified Catholic

religious entities…this ERISA trust [is] not subject to California state regulations [and] excludes coverage of direct

abortion of any kind.” In January 2015, the Guadalupanas Sisters no longer qualified for the ERISA trust and were

http://mgsps.org/carisma-charism/





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2. Skyline Wesleyan Church (“Skyline Church”)

Skyline Church is a non-profit Christian church located in La Mesa, California.26 As a

member of the Wesleyan denomination, Skyline Church “adheres to the Wesleyan Doctrinal

Statement, including the belief that the Holy Bible is the inspired Word of God, infallible and

without error.”27 Skyline Church believes abortion “is a grave moral evil,”28 that “violates the

Bible’s command against the intentional destruction of innocent human life,” and “is inconsistent

with the dignity conferred by God on creatures made in His image.”29 “Skyline Church believes

and teaches that participation in, facilitation of, or payment for an elective or voluntary abortion is

a grave sin.”30 Skyline Church expects its employees in their work and personal lives to abide by

Skyline Church’s religious beliefs and teachings on abortion.31 “Because of its religious beliefs . . .

Skyline Church seeks to offer health insurance coverage to its employees in a way that does not

also cause it to pay for abortions.”32

On September 22, 2017, Skyline Church filed a complaint with OCR alleging that the

Mandate Letters violate the Weldon Amendment because California’s discrimination against

health care plans forced Skyline Church to provide insurance coverage for elective abortions,

“despite [its] sincerely held religious beliefs against abortion.”33 Prior to the Mandate Letters,

Skyline Church had been insured by Aetna under a plan that excluded elective abortion services.34

Skyline alleges that California’s actions deprived it of insurance coverage that was consistent with

its beliefs.

Although OCR’s investigation relates to the 2017 Guadalupanas and Skyline Complaints,

OCR also received complaints from other parties raising similar allegations.35

thus “compelled to seek recourse to commercial health plan markets to obtain health insurance for their sisters located

in California,” opting to obtain coverage through Kaiser. Id.

26 Compl. Declaratory & Injunctive Relief & Nominal Damages, ¶ 14, Skyline Wesleyan Church v. Cal. Dep’t of

Managed Health Care, No. 37-2016-000036 (Cal. Sup. Ct. Feb. 4, 2016), removed, No. 16-cv-00501 (S.D. Cal. 2018),

appeal filed, No. 18-55451 (9th Cir. Apr. 9, 2018).

27 Id. ¶ 15.

28 2017 Skyline Compl. at 1.

29 Compl. ¶ 22, Skyline Wesleyan Church (2018).

30 Id. ¶ 23.

31 Id. ¶ 26.

32 Id. ¶ 29.

33 2017 Skyline Compl. at 2.

34 Decl. REDACTED Supp. Pl.’s Mot. Summ. J., Skyline Wesleyan Church v. DMHC, No. 16-cv-00501, at ¶¶ 3-5

(S.D. Cal. Nov. 20, 2017).

35 See, e.g., Complaint filed by REDACTED, received through HHS OCR Complaint Portal (October 9, 2017)

(OCR Transaction No. 18-284511) (on file with HHS OCR); complaint filed by REDACTED, received through

HHS OCR Complaint Portal (Jan. 9, 2018) (OCR Transaction No. 18-338383) (on file with HHS OCR); and Letter

from REDACTED, Att’y for REDACTED, to Roger Severino, Dir., Office for Civil Rights (Aug. 24, 2018) (OCR

Transaction No. 18-316979) (on file with HHS OCR). See also Letter from Rep. Kevin McCarthy, House Majority

Leader, et al., to Hon. Sylvia Burwell, Sec., U.S. Dep’t Health & Human Servs., and Jocelyn Samuels, Dir.





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JURISDICTION

Congress has included the Weldon Amendment in the Departments of Labor, Health and

Human Services, Education, and Related Agencies Appropriations Act every year since 2004. The

Weldon Amendment states, in relevant part:

None of the funds made available in this Act may be made available to a . . . State

or local government, if such . . . government subjects any institutional or individual

health care entity to discrimination on the basis that the health care entity does not

provide, pay for, provide coverage of, or refer for abortions.36

The Weldon Amendment protects “institutional or individual health care entit[ies].”37

Under the Weldon Amendment, “the term ‘health care entity’ includes an individual physician or

other health care professional, a hospital, a provider-sponsored organization, a health

maintenance organization, a health insurance plan, or any other kind of health care facility,

organization, or plan.”38

The Weldon Amendment prohibits HHS from providing applicable funds to an entity that

discriminates in violation of the Amendment’s terms. As a recipient, through grants or cooperative

agreements, of the Federal funds from HHS that are subject to the Weldon Amendment, California

is, and has been, subject to 45 C.F.R. § 75.300(a), which requires HHS funds to be awarded and

implemented consistent with all U.S. statutory and public policy requirements, including

nondiscrimination requirements. Therefore, HHS has the authority to ensure that both it, and

covered entities, are spending Federal funds and operating programs consistent with the Federal

laws applicable to those funds and programs.

OCR’S INVESTIGATION

As part of OCR’s investigation, it sent a detailed data request39 to the California Health

and Human Services Agency (“CHHSA”) and the DMHC, requesting information about

California’s actions including “whether, and if so, how, the [CHHSA] and [DMHC], respectively,

implement, provide guidance on, enforce, or plan to enforce the Knox-Keene Health Care Service

Plan Act of 1975, (Cal. Health & Safety Code§ 1340 et seq.), the California Reproductive Privacy

Act (Cal. Health & Safety Code§§ 123460-123468), or Article 1, Section I, of the California

Constitution, with regard to California health plans that do not cover abortions in their evidence

Office for Civil Rights (June 28, 2016) (on file with HHS OCR); H. Rept. 115-862, at 122 (July 23, 2018)

(https://www.congress.gov/115/crpt/hrpt862/CRPT-115hrpt862.pdf).

36 E.g., 2020 Weldon Amendment, § 507(d)(1), 133 Stat. at 2607.

37 Id. § 507(d)(2).

38 Id. (emphasis added).

39 Letter from Michael Leoz, Regional Manager, Office for Civil Rights, U.S. Dep’t of Health & Human Servs., to

REDACTED, Sec., Cal. Health & Human Servs. Agency, and REDACTED, Dir., Cal. Dep’t Managed Health Care

(Oct. 2, 2017) [hereinafter “2017 Data Request”] (on file with HHS OCR).

https://www.congress.gov/115/crpt/hrpt862/CRPT-115hrpt862.pdf





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of coverage filings, subscriber documents, other plan documents, or otherwise, or plans that seek

approval without covering abortions.”40 OCR likewise inquired about enforcement of the Mandate

Letters and provided California copies of the Guadalupanas Sisters and 2017 Skyline Complaints,

along with notice of OCR’s investigation.41

OCR reviewed and analyzed California’s responses to the 2017 Data Request, as well as

data request responses, interview notes, and other related documents obtained during OCR’s

investigation of three complaints filed with OCR in 2014 concerning the Mandate Letters that had

been closed in 2016.42

OCR also reviewed and analyzed applicable pleadings, motions, briefs, discovery,

deposition transcripts, declarations, affidavits, hearing transcripts and videos, and court decisions

in the following matters:

Nat’l Family Planning & Reprod. Health Ass’n, Inc. v. Gonzales, No. 04-cv-02148 (D.

D.C. 2005).

Nat’l Family Planning & Reprod. Health Ass’n, Inc. v. Gonzales, No. 05-5406 (D.C.

Cir. 2006).

California ex rel. Lockyer v. United States, No. 05-cv-00328 (N.D. Cal. 2005).

California ex rel. Lockyer v. United States, Nos. 05–17292, 05–17312, 450 F.3d 436

(9th Cir. 2006).

Connecticut, et al. v. United States, No. 09-cv-00054 (D. Conn. 2009).

Missionary Guadalupanas of the Holy Spirit, Inc. v. Rouillard, No. 34-2015-80002226

(Cal. Super. Ct. 2015).

Missionary Guadalupanas of Holy Spirit Inc. v. Rouillard, No. C083232 (Cal. Ct. App.

2019).

Skyline Wesleyan Church v. Cal. Dep’t of Managed Health Care, No. 16-cv-0501 (S.D.

Cal. 2016).

Skyline Wesleyan Church v. Cal. Dep’t of Managed Health Care, No. 18-55451 (9th

Cir. 2018).

Foothill Church, et al. v. Rouillard, No. 15-cv-02165 (E.D. Cal. 2015).

Foothill Church, et al. v. Rouillard, No. 19-15658 (9th Cir. 2019).

40 2017 Data Request at 3.

41 Id.; Letter from Luis E. Perez, Deputy Director, Conscience and Religious Freedom Div., to REDACTED, Sec.,

Cal. Health & Human Servs. Agency, and REDACTED, Dir., Cal. Dep’t Managed Health Care, et al. (Aug 30, 2018)

(on file with HHS OCR).

42 On June 21, 2016, OCR closed the complaints and declined to make any finding of violation. See Letter from

Jocelyn Samuels, Dir., Office for Civil Rights, U.S. Dep’t of Health & Human Servs., to REDACTED, Vice Pres. Of

Legal Affairs, Life Legal Defense Found., et al. (June 21, 2016) (“Samuels Letter”) (on file with HHS OCR).

However, on January 26, 2018, the Department announced that the Samuels Letter, and the analysis contained therein,

no longer reflects the views of HHS, OCR, or the HHS Office of the General Counsel. 83 Fed. Reg. 3880, 3890-91.





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FINDINGS AND ANALYSIS

1. The DMHC Enforced California’s Abortion Mandate against Health Care Entities that

Limited or Excluded Abortion Coverage.

As the gatekeeper to the California health plan issuer market, which provides health care

coverage to over 26 million Californians, the DMHC Director wields significant leverage through

its regulation of over ninety-six percent of “commercial and public health plan enrollment” within

the State of California.43 This translates to approximately 171 different health care service plans

and about 10,000 different products.44 With limited exceptions, a health plan issuer must obtain a

license from the DMHC Director to do business in California.45 The DMHC Director issues a

license when the Director determines that the health plan issuer’s application, which must contain,

among other materials, copies of the evidence of coverage form, satisfies the requirements of the

Knox-Keene Act.46 A health plan issuer’s failure to provide “basic health care services” is grounds

for disciplinary action.47 A health plan issuer that commits an act or omission constituting grounds

for disciplinary action may, after appropriate due process procedures, have its license suspended

or revoked, or face administrative penalties.48 Health plan issuers that do not comply with DMHC

directives are subject to penalties.49

The DMHC states that it “aggressively monitor[s]” health plan issuer compliance with the

Knox-Keene Act.50 Through post-license reviews and routine tri-annual surveys, DMHC states

that it monitors “all aspects of the health plan[ issuer]’s operations,” including “changes they make

to their operations . . . changes in service areas, contracts, benefits or systems.”51 If DMHC

identifies deficiencies, the DMHC “takes timely action against health plan[ issuer]s that violate the

law.”52 In 2017 alone, the DMHC closed 2,203 cases with penalties under the Knox-Keene Act,

with assessed penalties totaling $8.9 million.53

43 DEP’T OF MANAGED HEALTH CARE, CAL. HEALTH & HUMAN SERVS. AGENCY 2017 ANNUAL REPORT 10 at 3 (May

2018). Available at: http://dmhc.ca.gov/Portals/0/Docs/DO/2017-Annual-Report-web.pdf. [hereinafter “2017 Annual

Report”].

44 REDACTED Dep. 14:13-15:9.

45 See CAL. HEALTH & SAFETY CODE § 1349 (requiring licensure unless exempted by § 1343 of California’s Health

and Safety Code).

46 Id. §§ 1351, 1353.

47 Id. § 1386(b)(3)-(4).

48 Id. § 1386(a).

49 2017 Annual Report at 12 and 16. See also REDACTED Dep. 122:5-21 (testifying that failure of a healthcare plan

to provide coverage for all legal abortions is considered a violation of the Knox-Keene Act subject to administrative

penalties handled by the enforcement office).

50 2015 DMHC Data Resp. at 3.

51 2017 Annual Report at 10.

52 Id. at 2, 16.

53 Id. at 16.

http://dmhc.ca.gov/Portals/0/Docs/DO/2017-Annual-Report-web.pdf





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The DMHC Director informed each Health Plan Issuer that its “contracts contain language

that . . . limit[s] or exclud[es] coverage for termination of pregnancies.”54 The DMHC Director

also mandated each of the Health Plan Issuers to “amend current health plan [issuer] documents to

remove . . . coverage exclusions and limitations” for abortion.55 “These limitations or exclusions

include, but are not limited to, any exclusion of coverage for ‘voluntary’ or ‘elective’ abortions

and/or any limitation of coverage to only ‘therapeutic’ or ‘medically necessary’ abortions.”56

DMHC further instructed each Health Plan Issuer, within 90 days, to file an amendment to the

Health Plan Issuer’s license by submitting revised documents, such as evidence of coverage

forms.57

The Mandate Letters declared that the limitation or exclusion of abortion in health coverage

by health care entities is “inconsistent with the Knox-Keene Act and the California Constitution,”58

and effectively presented an ultimatum: Either amend and refile license documents in violation of

health care entities’ rights under the Weldon Amendment, or operate without approved plans and

face possible enforcement action for being in violation of California law as set forth in the Mandate

Letters.59 This action discriminated against plans on the basis that they did not cover all abortions,

notwithstanding the fact that DMHC had, for many years, consistently approved plan language

limiting abortion coverage.60

54 E.g., Aetna Letter at 1.

55 E.g., Aetna Letter at 2.

56 Id. (emphasis in original).

57 Id.

58 E.g., Aetna Letter at 2. In a lawsuit filed by Missionary Guadalupanas challenging the DMHC’s issuance of its

Mandate Letters under the California Administrative Procedure Act, the California Court of Appeals determined that,

“[b]ecause California law guarantees every woman the right to choose whether to bear a child or obtain an abortion,

the only legally tenable interpretation of the law is that abortions are basic health care services, which health care

service plans are required to cover.” Missionary Guadalupanas of Holy Spirit Inc. v. Rouillard, 38 Cal. App. 5th 421,

427-28 (Cal. Ct. App. 2019), review denied (Nov. 20, 2019).

59 See CAL. HEALTH & SAFETY CODE § 1386(b)(3)-(4) (identifying a health plan issuer’s failure to provide a basic

health care service as grounds for disciplinary action), and § 1386(a) (identifying that a health plan issuer that commits

an act or omission constituting grounds for disciplinary action may, after appropriate due process procedures, have its

license suspended or revoked or have to face administrative penalties).

60 See, e.g., Email Communications from REDACTED, Department of Managed Health Care, to REDACTED,

Associate General Counsel, Blue Shield CA, approving sample plan language that explicitly excluded coverage for

“services which are…for or incident to elective abortion.” (Sept. 12, 2008, 11:40am) (on file with HHS OCR); “[P]rior

to August 22, 2014, CDMHC’s position had been that voluntary abortions were not medically necessary under the

Knox-Keene Act such that managed health care plans were not required to provide coverage.” Anthem Blue Cross

Interview; “[T]here had been managed care products on the market for years with the option not to cover voluntary

abortions.” Telephone Interview with REDACTED, Western Region General Counsel, Aetna Health of CA (Feb. 26,

2015) (on file with HHS OCR) [hereinafter “Aetna Interview”]; “For religious groups, United Healthcare has

historically covered medically necessary termination of pregnancy” as opposed to covering “voluntary termination of

pregnancy… United Healthcare has refiled for certain religious employers since 1997 using the same preapproved

language regarding medically necessary termination of pregnancy.” Telephone Interview with REDACTED, Dir. of

Regulatory Affairs, United Healthcare et al. (Mar. 12, 2015) (on file with HHS OCR) [hereinafter “United Healthcare

Interview”]; See also Aetna Letter at 1. (“The DMHC has reviewed the relevant legal authorities and has concluded

that it erroneously approved or did not object to such discriminatory language in some evidence of coverage (EOC)

filings.”).





10

In response to the Mandate Letters, each of the issuers identified above removed coverage

exclusions and limitations regarding abortion coverage because they viewed these alterations in

their plan language as imperative for compliance.61 The mandated changes impacted at least 35

employer groups associated with at least 28,647 “lives enrolled” in health care plans that excluded

or limited abortion coverage,62 including thirteen that met the definition of “religious employer”

under California law.63

This estimate likely significantly underrepresents the number of lives impacted for two

reasons. First, this estimate is based on data from only five of the seven Health Plan Issuers.64

Second, relevant data from Kaiser used for this estimate represents the number of employer IDs

rather than lives enrolled.65 Because more than one “life enrolled” may be associated with an

employer ID,66 Kaiser’s data likely underrepresents the number of lives enrolled in its products

that limited or excluded abortion coverage.

2. California Does Not Exempt Health Care Entities that Otherwise Would Provide—and Did

Provide—Coverage Limiting or Excluding Abortion.

Subsequent to the release of the Mandate Letters, the California Court of Appeals ruled

that California law unequivocally requires health care service plans to cover abortion as a basic

health care service, but also upheld provisions of the Knox-Keene Act that allow “the [DMHC]

director [], for good cause, by rule or order” to exempt any plan or class of plan contracts from the

61 “Kaiser orally notified groups whose plans included abortion coverage restrictions that Kaiser was required to

comply with CDMHC’s August 22 letter…[Life Legal Defense Fund] encouraged Kaiser to challenge the August 22

letter but Kaiser advised [Life Legal Defense Fund] that it had no choice but to comply with the letter.” Telephone

Interview with REDACTED, Kaiser Executive Director of Policy, and REDACTED, Kaiser National Legal

Department Senior Counsel (Mar. 3, 2015) (on file with HHS OCR) [hereinafter “Kaiser Interview”]; “Aetna viewed

the amendment as necessary for regulatory compliance.” Aetna Interview; “United Healthcare was required to make

a filing pursuant to the [DMHC] letter.” United Healthcare Interview.

62 2015 DMHC Data Resp.at 5; Cal. Dep’t of Managed Health Care, Cal. Health & Human Servs. Agency, Health

Plan Responses to DMHC Abortion Data Call 000728-31 (Sept. 30, 2014) (on file with HHS OCR) [hereinafter

“DMHC Health Plan Issuer Responses”]. Of the 28,647 estimated, 22,747 represented “lives enrolled” in plan

products that limited or excluded abortion coverage for Anthem Blue Cross, Blue Shield, Health Net, Aetna, and

UnitedHealthcare, collectively. Id. The remainder of the estimate, 5,900, represented the number of employer IDs

associated with Kaiser plan products that limited or excluded abortion coverage. Id. at 000729. DMHC had this

information prior to issuing the Mandate Letters. See REDACTED Dep. 90:17-94:13, 103:2-6, 104:23-105:1, 107:2-

7, 117:22-118:8; Aetna, DMHC Data Call – Abortion Coverage, Ex. E-1 (July 2, 2014) (AGO000467) (on file with

HHS OCR) (responding to “data call issued . . . June 10, 2014, in which the Department seeks . . . the number of

employer groups that have purchased coverage that limits or excludes abortion services . . . the number of those

employers that would qualify as a ‘religious employer’ . . . [and] the total number of lives covered by [such] plans. . .

.”).

63 DMHC Health Plan Issuer Responses at 000728; See CAL. HEALTH & SAFETY CODE § 1367.25(c)(1) (defining

“religious employer”).

64 DMHC requested information from six of the seven Health Plan Issuers affected and received estimates from Kaiser,

United Healthcare, Blue Shield, Aetna, and Health Net. 2015 DMHC Data Resp.at 4. Anthem did not respond. Id. at

5 n.5. DMHC did not request data from GEMCare due to its small enrollment figures and status of its commercial

business. Id.

65 DMHC Health Plan Issuer Responses at 000730 n.5.

66 Id.





11

requirement to provide all basic health care services, including abortion.67 While exemptions are

at the discretion of the director, there are no written rules, policies, or procedures governing how

to handle an exemption request.68

The Mandate Letters did not reference any available exemption process,69 but did state (in

a footnote) that no “religiously sponsored health carrier” may be required by law “to participate in

the provision of or payment for a specific service if they object to doing so for reason of conscience

or religion.”70 This reference is a nearly verbatim copy of a Washington State insurance statute,71

except it excludes, without explanation, the text of a key subsection which states, “[n]o individual

or organization with a religious or moral tenet opposed to a specific service may be required to

purchase coverage for that service or services if they object to doing so for reason of conscience

or religion.”72 This indicates that, while DMHC may have contemplated the possibility of

exempting “religiously sponsored health carriers” (without explaining how an entity qualifies as a

“carrier”), it would not, at the same time, exempt religious individuals73—who object to paying

for abortion coverage for themselves, their children, or others in the insurance pool—and would

not exempt religious organizations, such as Complainants, that object to purchasing abortion

coverage for their employees.

OCR notes that the DMHC discussed granting an exemption with some of the health care

entities, and granted Anthem Blue Cross an exemption “to offer products that restrict abortion

coverage to employers that meet the definition of a religious employer” under California law.74

However, this lone exemption does not cure the impact of the Mandate Letters.

67 CAL. HEALTH & SAFETY CODE § 1367(i); Missionary Guadalupanas of Holy Spirit Inc. v. Rouillard, 38 Cal.

App. 5th 421, 439 (Cal. Ct. App. 2019), review denied (Nov. 20, 2019) (“the director clearly has the authority to

exempt plan contracts from the requirements of the Knox-Keene Act.”).

68 Sept. 19, 2017 Deposition of REDACTED, Dep. Dir. Legal Affairs, DMHC (on file with OCR) 32:18; 35:17.

69 Sept. 28, 2017 Deposition of REDACTED, Dir., DMHC (on file with HHS OCR) 45:14-19; REDACTED Dep.

130:9-12.

70 Aetna Letter at 1, n.3.

71 Compare, e.g., Aetna Letter at 1, n.3 with WASH. REV. CODE ANN. § 70.47.160(2)(a) (“No individual health care

provider, religiously sponsored health carrier, or health care facility may be required by law or contract in any

circumstances to participate in the provision of or payment for a specific service if they object to so doing for reason

of conscience or religion.”).

72 WASH. REV. CODE ANN. § 70.47.160(3)(a). Ms. REDACTED was instructed by counsel not to answer why the

Mandate Letters excluded this subsection. See REDACTED Dep. 48:19-49:7.

73 Complainants’ religious beliefs regarding abortion are shared by their employees. See Consolidated Opening Br.

Pet’ Opp’n Demurrer, & Supp. Writ Mandamus & Declaratory Relief at 4, Missionary Guadalupanas of the Holy

Spirit, Inc. v. Rouillard, No. 34-2015-80002226, at 8 (Cal. Super. Ct. Aug. 12, 2016) (“Petitioner’s members have

therefore been coerced into financially supporting procedures that they believe involve the killing of other human

lives, in violation of their deeply-held religious and moral convictions.”); Pl.’s Mem. Points & Authorities Supp. Mot.

Summ. J., Skyline Wesleyan Church v. DMHC, No. 16-cv-00501, at 16 (S.D. Cal. Nov. 20, 2017) (“Enforcing the

abortion mandate against the church’s internal healthcare decisions simply is not in the public interest. The only people

affected are those who work at the church, and they necessarily share the church’s beliefs about abortion.”).

74 2017 DMHC Data Resp. at 5, citing CAL. HEALTH & SAFETY CODE § 1367.25(c); see also Order Granting Def.’s

Cross Mot. Summ. J. at 4, Skyline Wesleyan Church, No. 3:16-cv-0501 (S.D. Cal. March 9, 2018).





12

First, California was put on notice of the burdens imposed by the Mandate Letters by

complaints filed with OCR and through long-running lawsuits over these issues filed by private

entities (including the Complainants in this matter). Lawsuits are strong and explicit requests for

relief, yet the State has refused to provide any relief at all in response to the litigation.75

Second, the only exemption California offered (to a health plan issuer) was limited to plans

covering a narrow set of “religious employers” under California law.76 However, the Weldon

Amendment protects from discrimination all plans that decline to cover abortion, without requiring

any plan issuers, sponsors, or beneficiaries to have a religious character or have a religious reason

for not providing or paying for such coverage. Based on the information available to OCR about

those affected by the DMHC policy, even a categorical exemption of “religious employers,” as

defined by California law, would have only been available to approximately 37% of those

employer groups who, prior to the Mandate Letters, had health care coverage that limited or

excluded abortion.77

Third, for California’s regime to be compliant with the Weldon Amendment, exemptions

from the abortion mandate cannot be discretionary, but rather, must be available to all health care

entities that desire to limit or exclude coverage of abortion.

Fourth, the DMHC Director has never exempted abortion-free plans as a class,78 nor the

plans purchased by the Complainants at issue here, despite the fact that compliance with federal 75 To OCR’s knowledge, DMHC has not taken any action to ensure Skyline Church has access to an exempted plan,

despite having knowledge, since 2014, of the fact that Skyline Church meets the definition of a “religious employer”

under California law, and possessing the statutory authority to exempt any person or plan contract from the abortion

requirement. See Letter from REDACTED, Legal Counsel for Skyline Wesleyan Church, Foothill Church, Calvary

Chapel Chino Hills, and Shepherd of the Hill Church, to REDACTED, Dir., DMHC (July 12, 2018) (attached as Ex.

1 to Appellant’s Mot. Supplement Record, Skyline Wesleyan Church v. DMHC, No. 18-55451 (9th Cir. Sept. 14, 2018);

Appellants’ Opening Br., Foothill Church v. Rouillard, No. 19-15658, at 43 (9th Cir. Aug. 14, 2019) (“Five years later,

the DMHC still refuses to make a similar accommodation for churches whose religious beliefs allow for abortion only

when necessary to save the life of the mother.”). See also Oral Arg., 23:58-24:06, Skyline Wesleyan Church v. DMHC,

No. 18-55451 (9th Cir. Nov. 4, 2019) (https://www.ca9.uscourts.gov/media/view_video.php?pk_vid=0000016448).

(Statement by Friedland, J. to counsel for DMHC: “I don’t understand why we should think that they really have a

chance of getting an exemption when you’ve been fighting this tooth and nail.”).

76 California defines “religious employer” narrowly to include only those employers for which:

(A) The inculcation of religious values is the purpose of the entity.

(B) The entity primarily employs persons who share the religious tenets of the entity.

(C) The entity serves primarily persons who share the religious tenets of the entity.

(D) The entity is a nonprofit organization as described in Section 6033(a)(3)(A)(i) or (iii) of the Internal

Revenue Code of 1986,1 as amended.

Cal. Health & Safety Code § 1367.25(c)(1).

77 See supra, discussing the policy’s known impact on at least 35 employer groups, 13 of which met the definition of

“religious employer” under California law, and 28,647 lives enrolled.

78 See REDACTED Dep. 57:3-9. The DMHC Director claims that she cannot commit as to whether DMHC would

approve a product sold to religious employers that excluded abortion in all cases, including rape and incest, except to

save the life of the mother. REDACTED Dep. 51:8-54:17. California claims it has not had a chance to evaluate such

a request. See Ans. Br. at 14, Skyline Wesleyan Church v. DMHC, No. 18-55451 (9th Cir. Dec. 14, 2018) (“Yet, no

health plan has sought an exemption for a product that excludes all abortion coverage (including in cases of rape and

incest, where the only exception is to protect the life of the woman. SER 83.”) (citing Decl. REDACTED Supp.

Defs’ Mot. Summ. J. or in the Alt. Summ. Adjudication Claims at ¶ 2, Skyline v. DMHC, No. 16-cv-00501 (S.D. Cal.

Nov. 20, 2017)

https://www.ca9.uscourts.gov/media/view_video.php?pk_vid=0000016448





13

law, namely, the Weldon Amendment, is per se good cause for doing precisely that, and DMHC

has long been aware of the conflict.

Finally, before concluding this investigation, OCR wrote California, asking it to confirm

or deny whether it would utilize the exemption process under state law “to align DMHC practices

to be consistent with the Weldon Amendment” and to clearly provide relief to all plans as a class

so that they may decline to provide abortion coverage without discrimination by the State.79 In

response, California ignored OCR’s specific request and instead reasserted its purported authority

to issue the Mandate Letters and stated that it would consider exemption requests from regulated

health plan issuers without any reference to how such requests will be solicited, treated, or

resolved, if at all.80 California’s response further confirms its non-compliance.

3. California’s Arguments Regarding the Weldon Amendment Fail.

California has argued that, because the “[Health Plan Issuers] that received the letter

already covered the legally required abortion services for the vast majority of their enrollees . . .

the requirements outlined in the letter do not discriminate against the [Health Plan Issuers] for

failure to cover abortion.”81 California misconstrues the plain language of the Weldon

Amendment.

Pursuant to the Weldon Amendment, a covered state or local government has an absolute

duty to refrain from subjecting “any . . . health care entity to discrimination on the basis that the

health care entity does not . . . provide coverage of . . . abortions.”82 It is irrelevant that some or

even most of the Health Plan Issuers’ plans covered abortion without exclusion or limitation,

because the Weldon Amendment plainly defines a protected “health care entity” as a “health

insurance plan . . . or any other kind of health care…plan.”83 An issuer protected by Weldon does

not lose protection because they do not object to abortion coverage in 99% of their plans, just as a

covered health care professional does not lose the right to be free from state discrimination for

refusing to participate in partial-birth abortions because they are willing to participate in early-

term medication abortions.

(“To date, no plan has requested an exemption that would mandate that women who become pregnant as a result of

rape or incest be forced to carry to term.”)). However, there is evidence in the record indicating DMHC approved such

a plan in 2002. See Letter from REDACTED, Pres. and CEO, Daughters of Charity Health System, to

REDACTED, Esq., Associate Gen. Counsel, Blue Shield of Cal. (Aug. 20, 2008) at 2 (DMHC000026) (on file with

HHS OCR) (explaining DMHC had approved plan language since January 2002 that limited abortion coverage to

“only if the member’s life or member’s spouse’s life would be in jeopardy as a direct result of pregnancy due to an

existing medical condition.”).

79 See Letter from Roger Severino, Dir., Office for Civil Rights, U.S. Dep’t of Health & Human Servs., to

REDACTED, Dir., DMHC, et al. (Jan. 10, 2020) (on file with OCR).

80 Letter from REDACTED, Dept. Att’y Gen., Cal., to Roger Severino, Dir., Office for Civil Rights, U.S. Dep’t of

Health & Human Servs. (Jan. 21, 2010), at 2 (on file with OCR).

81 2015 DMHC Data Resp.at 1, incorporated by reference in 2017 DMHC Data Resp. at 1-2.

82 E.g., 2020 Weldon Amendment, § 507(d)(1), 133 Stat. at 2607.

83 Id. § 507(d)(2).





14

By broadly conditioning licensure on abortion coverage, California discriminated, and

continues to discriminate, against health care entities that did or would limit or exclude abortion

coverage precisely because they would not provide coverage for abortion.

CONCLUSION AND REMEDY

Based on the evidence gathered in its investigation, and having considered California’s

responses to the allegations in the complaints, OCR finds California in violation of the Weldon

Amendment84 for having discriminated, and continuing to discriminate, against health care plans

and issuers that did, or would otherwise, limit or exclude abortion coverage in their plan products.

Because California refuses, despite ample notice and opportunity, to provide exceptions or take

remedial action sufficient to comply with the Weldon Amendment, California’s violation is

ongoing, and implicates funding that HHS made available to it from the 2018, 2019, and 2020

Appropriations Acts applicable to the Department of Health and Human Services.

OCR is charged with helping ensure entities come into compliance with Federal laws

protecting conscience and prohibiting coercion in health care, including the Weldon Amendment.

Accordingly, OCR requests that the State of California notify OCR within thirty (30) days from

the date of this letter whether the State of California intends to continue to enforce the Mandate

Letters’ requirement that all health care plans cover abortions, or will instead agree to take

corrective action to come into compliance with the law and remedy the effects of its discriminatory

conduct. OCR stands ready to assist California in coming into compliance with the Weldon

Amendment.

If OCR does not receive sufficient assurance that California will cease requiring all health

care plans, as a class, to cover abortion, or that it is willing to negotiate in good faith towards that

end, OCR will forward this Notice of Violation and the evidence supporting OCR’s findings in

this matter to the appropriate HHS funding components for further action under applicable grants

and contracts regulations. Such referral may ultimately result in limitations on continued receipt

of certain HHS funds in accordance with the Constitution and applicable Supreme Court case law.

See, e.g., 45 C.F.R. § 75.371.

84 2018 Weldon Amendment, § 507(d), 132 Stat. at 764; 2019 Weldon Amendment, § 507(d), 132 Stat. at 3118; 2020

CR Weldon Amendment, § 507(d), 132 Stat. at 3118; 2020 Weldon Amendment, § 507(d)(1), 133 Stat. at 2607.





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ADVISEMENTS

Nothing in this letter precludes OCR from making referrals to any other HHS component

or other federal agencies, including the Department of Justice, for appropriate action.85

OCR will share this Notice of Violation with the Health Plan Issuers and with the

Complainants and their counsel. This Notice of Violation will be made available to the public and

may include redactions.

Sincerely,

/s/

Roger T. Severino, Director

/s/

Luis E. Perez, Deputy Director

Conscience and Religious Freedom Division

85 OCR will inform the State of California of any such referral.





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Cc:

The Honorable Gavin Newsom

Governor

State of California

1303 10th Street, Suite 1173


Sarah Ream

Deputy Director & General Counsel

California Department of Managed Health Care



Mark Ghaly

Secretary

California Health & Human Services Agency

1600 Ninth Street, Room 460


Michelle (Shelley) Rouillard

Director

California Department of Managed Health Care



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